By completing this Adverse Event Report form, you understand and agree to the collection of your personal information by Actelion Pharmaceuticals Australia Pty Limited ABN 32 097 278 512 (Actelion Australia) and its use and disclosure for the purpose of the reporting of an adverse event in accordance with the Therapeutics Goods Act 1989.
You acknowledge that we may need to provide access to your personal information for review by representatives of regulatory authorities. You also acknowledge that your personal information may need to be disclosed for public health purposes or as required by law.
If you do not provide your personal information, Actelion may not be able to process the Adverse Event Report or verify its contents.
Actelion will retain the personal information on this form for its records. It may store it on web-based database systems or servers located outside Australia and/or managed by third parties for the purposes of Actelion's business.
You acknowledge that your personal information may be transferred overseas to various countries, such as Switzerland, for purposes related to drug safety and for the purposes of Adverse Event Reporting to regulatory agencies. By completing this form you acknowledge that Actelion Australia will not be responsible for ensuring that the overseas entities comply with the Australian Privacy Principles and as a result Actelion Australia may not be liable under the Privacy Act if the recipient does not act consistently with the Australian Privacy Principles.